Severe malnutrition remains a problem for patients receiving maintenance hemodialysis (MHD). Dialysis patients often have poor appetites and low energy. This malnutrition is reflected in low serum albumin concentrations, a strong predictor of increased morbidity and mortality. (Moore and Lindenfield, Support Line 29(5):7-16 (October 2007)). Patients are often treated using diet liberalization, oral supplements and enteral feeding. When these methods are not effective intradialytic parenteral nutrition (IDPN) may be utilized for more aggressive nutrition repletion efforts.
IDPN is infused during the hemodialysis procedure. IDPN has been used for decades and has resulted in weight gain and improved protein levels in patients. (U.S. Publication No. 2005/0148647). The typical IDPN treatment delivers 4-6 mg/kg/minute of glucose for patients in need of carbohydrate control and 6-8 mg/kg/minute for patients who do not need carbohydrate control. Blood glucose must be monitored to avoid problems associated with insulin resistance, hyperglycemia and hypoglycemia. In some cases, insulin is also administered either in the IDPN solution or more typically separately administered subcutaneously to modulate blood glucose levels. IDPN generally contains 1.2-1.4 g/kg of amino acids. However, these amounts can be lowered for patients who do not tolerate protein well. Monitoring of serum bicarbonate and carbon dioxide levels must be monitored to check for acidosis caused by administration of amino acids. Lipids are provided in IDPN at a rate between 4 mg/kg/minute and 12-12.5 g/hour depending on tolerance of the lipids by the patient. Generally, these lipids are emulsions of purified vegetable oil from soybean (Intraliipid® from Kabi Vitrum or Travamulsion® from Travenol) or safflower oil (Liposyn® from Abbott). (Powers, Contemporary Dialysis and Nephrology:29-31 (February 1990).
IDPN is usually administered in one liter of solution, and occasionally micronutrients, like vitamins and minerals are co-administered in or with IDPN. IDPN has proved effective in decreasing morbidity and mortality in MHD patients, leads to increased levels of serum albumin and creatine levels, and increased body weight. (Moore and Celano, Nutrition in Clinical Practice, 20(2):202-212 (2005)). Hypoglycemia is another potential dangerous result of the administration of insulin during IDPN with symptoms of nervousness, sweating, intense hunger, trembling, weakness, palpitations, and trouble speaking.
Problems associated with IDPN include hyperglycemia, complications in patients with insulin resistance or other problems associated with glucose management, as well as complications in patients who require strict fluid management. The glucose concentrations administered with IDPN can cause hyperglycemia and hypoglycemia in some patients. The administration of insulin can sometimes successfully treat this hyperglycemia, but some patients demonstrate insulin resistance, and may not respond to insulin treatment. (Goldstein and Strom, Journal of Renal Nutrition 1(1):9-22 (January 1991)). Hyperglycemia is a major barrier to effective nutrition support even outside the context of hemodialysis. Many studies report associations between hyperglycemia and increased morbidity and mortality. McCowen and Bistrian, Nutrition in Clinical Practice, 19(3):235-244 (June 2004)). Moreover, the amount of fluid in typical IDPN treatment is a barrier to use in patients with strict fluid management. Thus, a need exists for an improved IDPN composition for administration to patients that diminishes hyperglycemia associated with IDPN administration and decreases the need for the administration of insulin with IDPN. Moreover, a need exists for a lower volume IDPN dosage form.